Nobody likes having severe pain in their “personal areas,” and as emergency physicians, we have an obligation to relieve these problems on both an immediate and long-term basis.

Bartholin Gland Abscess

Bartholin glands normally secrete lubrication into the vaginal vestibule via small ducts, but if they become occluded, cyst and abscess formation may follow. Draining an infected Bartholin gland is a common procedure in an emergency department, but this painful condition is likely to recur if we do not ensure that a new duct can form to allow the gland to drain normally.

There are several methods for creating a fistula from the abscess cavity, but one of the best ways is to leave a Word catheter in place for 2-4 weeks to allow a drainage channel to form.

Here’s the problem: Have you ever tried to find a Word catheter in your GYN room? They are usually right next to the fenestrated ear wicks, kryptonite dagger, and powdered unicorn horn. There are precedents for using a Foley catheter as an alternative, but telling a patient that she will have a 24-cm rubber tentacle hanging out of her groin for three weeks is a tough sell.^1,2

To make your own Word-like catheter, you’ll need a pediatric Foley Catheter (8 or 10 French, since larger sizes do not work well). You should also have hemostats and scissors, cyanoacrylate tissue adhesive (such as “Dermabond”), and a PPD or insulin syringe, in addition to your usual incision and drainage equipment.

I recommend applying topical EMLA to the vaginal mucosa to relieve the pain of local anesthetic injection, and I use preservative-free or buffered lidocaine if possible.

Once you have performed the I&D, place the deflated balloon of the Foley catheter into the abscess cavity. You may need a hemostat to help, since the tip just past the balloon that must also be in the cavity. Slowly inflate the balloon with 3-4 mL of saline or sterile water. Once you are sure it’s in place, clamp the Foley firmly with a hemostat several centimeters distal to the balloon. (Picture 1).

Next, use scissors to cut the catheter 2 cm distal to the clamp site. The proximal end of the catheter will eject the fluid from the balloon inflation channel, but the balloon itself will not collapse as long as you keep the hemostat in place. When you look at the catheter in cross-section, you’ll see the large central channel where urine normally drains, and in the 6 o’clock position a much smaller channel that conducts fluid to the balloon for inflation.

This smaller channel is your target. Draw up some of your tissue adhesive in an insulin or PPD syringe, and inject some of the adhesive directly into the balloon channel. (Picture 2).

Several “squirts” of adhesive may be used, and then be sure to apply a little pressure.

Do not remove the hemostat immediately. Give the adhesive a few minutes to harden. To pass the time, discuss basic aftercare instructions with the patient rather than just sitting there in awkward silence. Once you unclamp the hemostat, the tissue adhesive in the balloon channel will keep the balloon from deflating, and your patient now has a good chance at forming a fistula channel over the next several weeks.

Once the appropriate amount of time has passed (2-4 weeks), the balloon can be deflated and removed by simply cutting the catheter again, but this time proximal to where the adhesive is blocking the inflation channel. This action will deflate the balloon, allowing for easy removal. (Picture 3).

What could go wrong?

Give the patient the standard Word catheter precautions, and make sure they know that they do not have to panic if the catheter falls out – you can reduce this possibility by not making your incision overly large. The extra “tip” on the Foley catheter is not present on Word catheters, but it doesn’t seem to cause patients much extra discomfort in my experience.

Do not over-inflate the balloon, as this will cause the patient pain, and she may return insisting on premature removal. If you aren’t the doctor who will remove the catheter, type up a few simple instructions on deflating the balloon on the patient’s discharge paperwork to prevent panic and reprimands.

Anal Agony Aftermath

Anal pain doesn’t get a lot of respect, but we aren’t really in the respect business. It’s just plain rude to send home a patient after we’ve drained a perianal abscess, incised a hemorrhoid, or diagnosed an anal fissure without a little thoughtful aftercare.

The patient may look fairly comfortable in the department after we’ve just sliced her open with a #11 blade, but the real misery will come when he has that first bowel movement and the anus must distort, dilate, and disgorge with a raw wound in place. A few simple steps can prevent weeks of misery.

Lubrication and Anesthesia

Prescribe the patient lidocaine ointment 5%, topical bacitracin, stool softeners, and glycerin suppositories. When the patient feels the need to defecate, tell her to apply a mixture of lidocaine ointment and bacitracin and then insert a glycerin suppository. After about 15 minutes, he should be able to have a relatively pain-free bowel movement. An added benefit: Fecal matter is less likely to adhere firmly to the external anal region, making wiping much less torturous.

My Office Doesn’t Have a Bathtub

It makes no sense to tell patients to perform Sitz baths multiple times a day when they have to work for a living. For crying out loud, give your patients a disposable bedpan when you discharge them! This way they can discreetly fill it with warm water, place it on top of a toilet seat at work, and soak their way back to health.

References

1. Obstet Gynecol Surv. 2009 Jun;64(6):395-404.
2. J Emerg Med. 2009 May;36(4):388-90.